Public Burden Statement

A Federal agency may not conduct or sponsor, and a person is not required to respond to, nor shall a person be subject to a penalty for failure to comply with a collection of information subject to the requirements of the Paperwork Reduction Act unless that collection of information displays a current valid OMB Control Number. The OMB Control Number for this information collection is 2126-0006. Public reporting for this collection of information is estimated to be approximately 25 minutes per response, including the time for reviewing instructions, gathering the data needed, and completing and reviewing the collection of information. All responses to this collection of information are mandatory. Send comments regarding this burden estimate or any other aspect of this collection of information, including suggestions for reducing this burden to: Information Collection Clearance Officer, Federal Motor Carrier Safety Administration, MC-RRA, 1200 New Jersey Avenue, SE, Washington, D.C. 20590.

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U.S. Department of Transportation

Federal Motor Carrier

Safety Administration

Medical Examination Report Form

(for Commercial Driver Medical Certification)

SECTION 1. Driver Information (to be filled out by the driver)


(or sticker)


Last Name: First Name: Middle Initia: Date of Birth: Age: Street Address: City: State/Province: Zip Code: Driver’s License Numbe: Issuing State/Province: Phone: E-Mail (optional): CLP/CDL Applicant/Holder *:

Driver ID Verified By **:

Has your USDOT/FMCSA medical certificate ever been denied or issued for less than 2 years?


Have you ever had surgery? If “yes,” please list and explain below

Are you currently taking medications (prescription, over-the-counter, herbal remedies, diet supplements)?

If “yes,” please describe below.

**This document contains sensitive information and is for official use only. Improper handling of this information could negatively affect individuals. Handle and secure this information appropriately to prevent inadvertent disclosure by keeping the documents under the control of authorized persons. Properly dispose of this document when no longer required to be maintained by regulatory requirements.**

Last Name: First Name: DOB: Exam Date:


Do you have or have you ever had:



Not Sure



Not Sure

1. Head/brain injuries or illnesses (e.g., concussion)

17. Unexplained weight loss

2. Seizures/epilepsy

18. Stroke, mini-stroke (TIA), paralysis, or weakness

3. Eye problems (except glasses or contacts)

19. Missing or limited use of arm, hand, finger, leg, foot, toe

4. Ear and/or hearing problems

20. Neck or back problems

5. Heart disease, heart attack, bypass, or other heart problems

21. Bone, muscle, joint, or nerve problems

6. Pacemaker, stents, implantable devices, or other heart procedures

22. Blood clots or bleeding problems

7. High blood pressure

23. Cancer

8. High cholesterol

24. Chronic (long-term) infection or other chronic diseases

9. Chronic (long-term) cough, shortness of breath, or other breathing problems

25. Sleep disorders, pauses in breathing while asleep, daytime sleepiness, loud snoring

10. Lung disease (e.g., asthma)

26. Have you ever had a sleep test (e.g., sleep apnea)?

11. Kidney problems, kidney stones, or pain/problems with urination

27. Have you ever spent a night in the hospital?

12. Stomach, liver, or digestive problems

28. Have you ever had a broken bone?

13. Diabetes or blood sugar problems Insulin used

29. Have you ever used or do you now use tobacco?

14. Diabetes or blood sugar problems Insulin used

30. Do you currently drink alcohol?

15. Fainting or passing out

31. Have you used an illegal substance within the past two years?

16. Anxiety, depression, nervousness, other mental health problems

32. Have you ever failed a drug test or been dependent on an illegal substance?

Other health condition(s) not described above

Did you answer “yes” to any of questions 1-32?

If so, please comment further on those health conditions below: